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Asked by ralmonte1306

John is a 57-year old male who has been having severe abdominal pain for the past 4 hours. John called his primary care physician and was able to get a same-day appointment. John explained to his physician that he has had stabbing pain in the upper portion of his abdomen since he ate breakfast this morning. john’s provider sent him for some diagnostic tests. When John reviewed the results in his electronic medical record online, the physician noted “possible gastroesophageal reflux disease-GERD.”

What condition would be considered the first-listed diagnosis?
What would the documentation need to state for the coder to report the code for GERD?
Should the coder be looking for the results of the diagnostic tests and coding any abnormalities they notice?
SCIENCE
HEALTH SCIENCE
NURSING
MEDICAL CODING AND BILLING MCCG137 –

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